Hyperplasia of the Mandibular Condyle: Clinical, Histopathologic…fedicom.org/wp-content/uploads/2011/08/HiperplasiaCondi... · 2017-03-24 · Hyperplasia of the Mandibular Condyle:

J Oral Maxillofac Surgxx:xxx, 2010

Hyperplasia of the Mandibular Condyle:Clinical, Histopathologic, and TreatmentConsiderations in a Series of 36 Patients

Laura Villanueva-Alcojol, MD* Florencio Monje, MD, PhD and

Ral Gonzlez-Garca, MD

Purpose: Mandibular condylar hyperplasia (CH) is a rare entity that causes overdevelopment of themandible, creating functional and esthetic problems. The aim of this article was to describe demographicand clinical characteristics of CH, analyze histopathologic features and their association with scinti-graphic and clinical findings, and evaluate esthetic and functional results after treatment by highcondylectomy during the active phase.

Materials and Methods: This retrospective study included 36 patients whose condyles were removedbecause of excessive unilateral growth resulting in facial asymmetry and occlusal disturbance. Of the 36patients, 13 had had symptoms related to the temporomandibular joint, such as pain or clicking. In allthe cases, high condylectomy was performed, and surgical specimens were sent for histologic exami-nation and divided into 4 histologic types as described by Slootweg and Mller. Statistical analysis wasperformed by use of R software (version 2.10.1; R Foundation for Statistical Computing, Vienna, Austria)and SPSS software for Windows (version 15.0; SPSS, Chicago, IL) to evaluate our results. A 2 test wascarried out to assess the possible association between gender and involved side. The association ofhistologic appearance with clinical symptoms was estimated by use of the Fisher exact test. An analysisof variance test was performed to evaluate a possible association between patient age and histologic typeaccording to the Slootweg and Mller classification and between histologic type and uptake on bonesingle photon emission computed tomography (SPECT).

Results: We could not find a relationship between histologic type and uptake of the affected condyleon bone SPECT or between age and histologic type. However, our statistical analysis revealed anassociation between histologic appearance and the presence of joint symptoms (P .0049). Clinically,occlusion and facial symmetry improved in all patients postoperatively, and no recurrence was noted inany patient. Six patients required secondary surgery.

Conclusion: We could not find any significant association between age and histologic type or betweenbone SPECT and histologic type. However, a significant association between histologic type andtemporomandibular joint symptoms was observed. High condylectomy combined with orthodonticsachieved optimal esthetic and functional results and constituted the unique and definitive treatment in30 of 36 patients. 2010 American Association of Oral and Maxillofacial SurgeonsJ Oral Maxillofac Surg xx:xxx, 2010

Mandibular condylar hyperplasia (CH) is a rare entity.It was first described by Robert Adams in 1836 as acondition that causes overdevelopment of the mandi-ble, creating functional and esthetic problems.1 Since

then, there have been numerous reports in the liter-ature referring to this clinical entity.2-4 The excessiveunilateral growth of the mandibular condyle can leadto facial asymmetry, occlusal disturbance, and joint

Received from the Department of Oral and Maxillofacial-Head and

Neck Surgery, University Hospital Infanta Cristina, Badajoz, Spain.

*Resident Surgeon.

Department Head.

Staff Surgeon.

Address correspondence and reprint requests to Dr Villanueva-

Alcojol: Department of Oral and Maxillofacial Surgery, University

Hospital Infanta Cristina, Badajoz, Juan de Badajoz, 14, 2G, 06003

Badajoz, Spain; e-mail: [email protected]

2010 American Association of Oral and Maxillofacial Surgeons

0278-2391/10/xx0x-0$36.00/0

doi:10.1016/j.joms.2010.04.025

1

ARTICLE IN PRESS

www.fedicom.org

axillofac SurgSurg2010

dyle:le:atmentment

PatientstientsPhD and

causes overdevelopment ooverdeveloprticle was to describe demowas to describe

es and their association wd their associaional results after treatmeresults after tre

36 patients whose condyleatients whose coymmetry and occlusal distuetry and occl

mandibular joint, such as palar joint, suchrgical specimens were sentcimens were

ed by Slootweg and MllerSlootweg and MFoundation for Statistical Coation for Stat

PSS, Chicago, IL) to evaluathicago, IL) tobetween gender and invobetween gender and

s was estimated by use of thwas estimated by usa possible association betwepossible associa

assification and between hassification and betwography (SPECT).phy (SPECT

onship between histologic tp between histoand histologic type. Howstologic type.

ppearance and the presencnce and the primproved in all patients pooved in all patien

uired secondary surgery.secondary sur

ot find any significant associot find any significantogic type. However, a siggic type. However,

int symptoms was observesymptoms was ohetic and functional resultsand functiona

n Association of Oral andociation of Orafac Surg xx:xxx, 2010urg xx:xxx, 201

ondylar hyperplasia (CH) isr hyperplasia (Cdescribed by Robert Adamibed by Robert

that causes overdevelopmecauses overdevating functional and esthetifunctional and e

ww

eived from the Department of Oraom the Departm

eck Surgery, University Hospital Iery, University Ho

*Resident Surgeon.ident Surgeon

Department Head.Department Head.

Staff Surgeon.Staff Surgeon.

Address correspondenAddress

Alcojol: Department ofAlcojol: Dep

dysfunction. Prominent features include an enlargedmandibular condyle, elongated condylar neck, out-ward bowing, and downward growth of the body andramus of the mandible on the affected side, causingfullness of the face on that side and flattening of theface on the contralateral side. Some patients also maypresent with symptoms from the temporomandibularjoint (TMJ) such as pain, joint sounds, and limitationof mouth opening.5

Obwegeser and Makek6 classified the asymmetryassociated with CH into 3 categories: hemimandibularelongation, with a horizontal growth vector (type 1);hemimandibular hyperplasia, with a vertical growthvector (type 2); and a combination of the 2 entities.Type 1 is associated with chin deviation toward thecontralateral side and mandibular midline deviated tothe unaffected side. On the other hand, type 2 ischaracterized by an ipsilateral open bite or compen-satory vertical overdevelopment of the maxilla on theinvolved side with canting of the occlusal plane. Mostcommonly, the mandibular midline is straight and thechin is less deviated. The third type is a combinationof the other 2 types.

The etiology and pathogenesis of CH remain uncer-tain. It is not known what triggers a condyle to sud-denly start growing and become hyperplastic. Sug-gested theories include trauma followed by excessiveproliferation in repair, infection, hormonal influ-ences, arthrosis, hypervascularity, and a possible ge-netic role.7-9 Obwegeser and Makek6 suggested thatdifferent growth factors individually controlling gen-eralized hypertrophy and elongation might be respon-sible for the deformities. Another possible cause be-ing taken into consideration, but thus far notsubstantiated, is an increase in functional loading ofthe TMJ.10,11

The diagnosis of CH may be made by a combinationof clinical and radiologic findings. Various methodshave been used, including radiographic studies, bone

scintigraphy, and histopathologic assessment.5,12 TMJradiographs may show abnormalities in the size andmorphology of the condylar head and/or neck re-gions. Bone single photon emission computed tomog-raphy (SPECT) scan is an essential diagnostic tool forvisualizing hyperactivity in the condyle. Various stud-ies have shown the clinical significance of this tech-nique in such patients because this method identifiesthose with persistent unilateral condylar activity.5,13,14

The radioactive isotope is technetium 99 methylenebisphosphonate. Increased radionuclide uptake bythe hyperplastic condyle can be an indication of con-tinued abnormal growth. It has been reported that adifference in uptake of 55%:45% or more between thecondyles can be indicative of CH, because the af-fected condyles had a relative uptake of 55% ormore.15-17

Slootweg and Mller12 described 4 histologicallydifferent types of mandibular CH. They proposed aclassification based on histologic criteria and dividedhyperplastic condyles into 4 types depending on thearrangement and morphology of the various layers ofthe condyle (fibrous articular layer, undifferentiatedmesenchyme proliferative layer, transitional layer,and hypertrophic cartilage layer)18 (Table 1).

Although most reported cases are documented his-tologically,5,12,19,20 in general, correlation of histo-logic aspects with age, SPECT, and clinical symptomsremains unclear.

Treatment is primarily surgical, with or withoutorthodontics, and depends on the degree of severityand the status of condylar growth. Different surgicaloptions have been proposed for treating this anomaly,ranging from high condylectomy to orthognathic sur-gery or even a combination of both. There is alsocontroversy with respect to the time of surgery, withsome authors preferring to perform surgery as soon aspossible and others waiting for cessation of excessiveactivity to perform any intervention.

Table 1. HISTOLOGIC CLASSIFICATION OF MANDIBULAR CONDYLAR HYPERPLASIA DESCRIBED BY SLOOTWEGAND MLLER12

Histologic Classification Characteristics

Type I Broad proliferation zoneUnderlying thick layer of hyaline growth cartilageBone containing numerous cartilage islands

Type II Patchy distribution (cell-rich areas alternating with nonproliferative, cell-poor zones)Cartilage islands in cancellous bone are less frequent than in type I

Type III Great distortionIrregularly shaped masses of hyaline cartilage extending into cancellous bone of condylar neck

or encroaching upward onto superficial articular layerType IV Continuous subchondral bone plate covered by cell-poor fibrocartilaginous layer

No proliferation layer of hyaline growth cartilageBurned-out appearance of condyle

Villanueva-Alcojol, Monje, and Gonzlez-Garca. Hyperplasia of the Mandibular Condyle. J Oral Maxillofac Surg 2010.

2 HYPERPLASIA OF THE MANDIBULAR CONDYLEARTICLE IN PRESS

www.fedicom.org

w.

ud-ud-Sug-ug-

cessiveessival influ-l influ-

ossible ge-e ge-ggested thated that

ontrolling gen-ng gen-might be respon-e respon-

possible cause be-ble cause be-but thus far notthus far no

functional loading offunctional loading o

be made by a combinationmade by a combinafindings. Various methodngs. Various

ng radiographic studies, boraphic studi

sment..5,125,12 TMJTMJin the size andhe size and

d and/or neck re-or neckon computed tomog-ted tomog-

tial diagnostic tool foragnostic tool fore condyle. Various stud-dyle. Various

l significance of this tech-cance of thiscause this method identifies method ide

nilateral condylar activity.ylar activ 5,13

pe is technetium 99 methyum 9ncreased radionuclide uptaed radionuclide

condyle can be an indicatioe can be an indal growth. It has been repowth. It has been

uptake of 55%:45% or moree of 55%:45% oran be indicative of CH, bindicative of

ondyles had a relative ups had a relativ7

otweg and Mllerg and Mller1212 descriderent types of mandibulartypes of man

assification based on histolion based onhyperplastic condyles intotic condylesarrangement and morphoangement and mthe condyle (fibrous ahe condyle (fimesenchyme prolifemesenchymeand hypertrophic cnd hypertrop

Although mostAlthoughtologically,tologic 5,12,1

logic aspectslogic asremains unremai

TreatmTorthodoorand toptra

SSIFICATION

wwwassificationype I Broad prolifBroaUnderlyinUndBone coType IIpe II Patchy

CartType IIIype III Gr

I

Type IVType IV

Villanueva-Alcojol, MVillanueva-A

CONDYLEYLE

The aim of this retrospective study was to describe,in a group of 36 patients diagnosed with unilateralCH, demographic and clinical characteristics; analyzehistopathologic features of CH and their associationwith scintigraphic and clinical findings; and evaluateour esthetic and functional results after treatment byhigh condylectomy during the active phase.

Materials and Methods

This retrospective study, which covered the periodbetween 1998 and 2009, included 36 patients (25female and 11 male patients) whose condyles wereremoved because of excessive unilateral growth re-sulting in facial asymmetry and occlusal disturbance.

The inclusion criteria for the study were 1) patientswith facial asymmetry and malocclusion, with orwithout pain or clicking related to the TMJ; 2) pa-tients who showed enlarged and/or elongated con-dyles on the orthopantograph; 3) patients whoseSPECT scan showed a difference in uptake of 55%:45% or more between condyles or a large differenceassessed subjectively by a specialist in nuclear medi-cine; and 4) patients in whom histopathologic exam-ination confirmed mandibular CH.

Exclusion criteria included patients in whom en-largement of the condyle was caused by neoplasia ordysplasia, as shown by radiologic and histologic ex-amination. All patients were informed of the nature ofthis investigation and all provided their informed con-sent.

Each patient had a complete clinical examination.The presenting clinical features in these patients in-cluded facial asymmetry and malocclusion. Moreover,13 of the 36 patients had had symptoms related to theTMJ. In each case, these consisted of mild pain andclicking. Apart from the clinical examination, plainradiographs with orthopantographs and posteroante-rior and lateral cephalograms were obtained. Theseshowed enlarged and/or elongated condyles in mostcases.

In all 36 cases, bone SPECT scans were performed.Patients who had a ratio of 55%:45% or more andclinical and radiographic findings in accordance withCH were operated on. A 6-month to 1-year patientevaluation period was sometimes required before sur-gery in cases in which condylar activity was uncer-tain. Exceptionally, 1 patient with an uptake of 54%:46% after several scintigraphic studies was treatedsurgically because of persistent and increasing symp-toms after various evaluations.

In relation to the scintigraphic study, we mustpoint out that only 24 of the SPECT scans were quan-tified. In the earlier cases, the planar and SPECT im-ages were assessed only subjectively by a specialist innuclear medicine.

In all the cases in our series, high condylectomywas performed through an intra-aural or preauricularapproach, incision on the superficial temporal fasciaand periosteum of the zygomatic arch, and dissectionjust above the TMJ capsule. Then, a T-incision wasperformed for entry in the inferior joint space, and 4to 5 mm of the condylar head was removed, withoutsmoothing of the cortical edges. Orthodontic treat-ment and mouth opening exercises were startedthereafter.

All surgical specimens were sent for histologic ex-amination. The condyles were first placed in 4% buff-ered formalin and then decalcified in hydrochloricacid (Surgipath Medical, Richmond, IL) and dehy-drated sequentially in 70%, 90%, and 100% alcohol.Samples were cleared with 50% and 100% methylsalicylate before infiltration with paraffin. Micrometersections were prepared from blocks, deparaffinized inxylene, rehydrated in descending concentrations ofalcohol, and stained with hematoxylin-eosin. The sam-ples were subsequently divided into 4 histologic typesas described by Slootweg and Mller.12

All the cases were confirmed histopathologically asCH, but only 18 were divided according to the Slootwegand Mller classification. We compared the histology ofthe condylar specimen with preoperative bone scintig-raphy to try to find functional-morphologic correlations.

STATISTICAL ANALYSIS

Statistical analysis was performed by use of R soft-ware (version 2.10.1; R Foundation for StatisticalComputing, Vienna, Austria) and SPSS software forWindows (version 15.0; SPSS, Chicago, IL). The levelof statistical significance was set at .05. The descrip-tive statistical analysis was based on the mean andstandard deviation for continuous variables, whereasthe frequency and percentage were used for categor-ical variables. A 2 test was carried out to assess thepossible association between gender and involvedside. The association of histologic appearance withclinical symptoms was estimated by use of the Fisherexact test. An analysis of variance (ANOVA) test wasperformed to evaluate a possible association betweenpatient age and histologic type according to the clas-sification of Slootweg and Mller and between histo-logic type and uptake on bone SPECT.

This study was approved by the Hospital EthicalCommittee and by the Institutional Human Studies(IRB) Committee.

Results

The mean age at surgical intervention was 22.7years (SD, 6.7; range, 11 to 42 years). The female-male

VILLANUEVA-ALCOJOL, MONJE, AND GONZLEZ-GARCA 3ARTICLE IN PRESS

www.fedicom en-en-asia orasia o

ogic ex-gic ex-e nature ofure of

formed con-d con-

cal examination.mination.these patients in-e patients in-

occlusion. Moreover,ion. Moreovermptoms related to themptoms related to th

nsisted of mild pain andsisted of mild pain anlinical examination, plainical examination, p

antographs and posteroanteaphs and poograms were obtained. Theere obtaine

/or elongated condyles inongated condyl

bone SPECT scans were pePECT scans wead a ratio of 55%:45% orratio of 55%

adiographic findings in accophic findings iperated on. A 6-month toed on. A 6-mon

n period was sometimes reqod was sometimcases in which condylar ain which cond

Exceptionally, 1 patient witonally,% after several scintigraphir several sci

urgically because of persistey because of ptoms after various evaluatioafter various ev

In relation to the scin relation topoint out that only 24 ooint out that onltified. In the earlier cified. Inages were assessedages werenuclear medicinenuclear me

com.orgcondylectomyylectomyl or preauricularreauricularial temporal fasciamporal fasarch, and dissectiondissectionhen, a T-incision wasa T-incision waferior joint space, and 4joint space,

ead was removed, withoutremoved, wial edges. Orthodontic treaOrthodontic

ening exercises were stares were

mens were sent for histolowere sent for hondyles were first placed ins were first plac

and then decalcified in hyhen decalcifiedath Medical, Richmond, ILedical, Richmo

uentially in 70%, 90%, andlly in 70%, 90%were cleared with 50% acleared with 5

te before infiltration with pore infiltration wons were prepared from bloere prepared fro

ene, rehydrated in descenehydrated inlcohol, and stained with hemnd stained wi

ples were subsequently divwere subsequentas described by Slootwedescribed by S

All the cases were cAll the casesCH, but only 18 wereCH, but only 18and Mller classificnd Mller clathe condylar spethe condylraphy to try toraphy to

STATISTIS

StatiswareComW

333

ratio was 25:11, and the right-left affected side ratiowas 11:7 (22 right and 14 left) from SPECT, histolog-ically and clinically.

It has been suggested that there is an associationbetween female gender and right side, with the rightside predominating in female patients and the left sidepredominating in male patients.21 In our sample, wecould not find a statistically significant associationbetween gender and affected side.

All patients had unilateral excessive growth of themandibular condyle with concomitant occlusal distur-bance and/or chin deviation toward the opposite side.According to the clinical classification of Obwegeserand Makek,6 24 patients were considered type 1(66.7%), 8 patients showed an asymmetry in the verticalplane and were classified as type 2 (22.2%), and a com-

bination of the 2 types was seen in 4 patients (11.1%).Additional symptoms, such as mild pain or clicking ofthe joint, were present in 13 cases (36.1%).

Bone SPECT scan had been performed on all 36 sub-jects. On all the scans, there was appreciable asymmetryin relative condylar uptake. The maximum differenceamong quantified scans was 68% to 32%. The meanpercentage of the affected condyle was 59.04% (SD,3.56), whereas the unaffected condyle showed a lowerpercentage (40.96%; SD, 3.56) (Table 2).

On examination of the histologic sections, all pa-tients exhibited a persistent layer of undifferentiatedmesenchyme cells and a layer of hypertrophic carti-lage, and evidence of cartilage rests in the cancellousbone. Classification into types according to Slootwegand Mller was only performed in 18 patients, as

Table 2. CLINICAL DATA OF 36 PATIENTS WITH MANDIBULAR CONDYLAR HYPERPLASIA

Patient Age (yr) Gender Side SPECT Clinical Type* TMJ Symptoms Secondary Surgery

1 27 F R 1 No No2 24 F R 2 Yes Yes3 24 M L 2 No No4 26 F L 2 No No5 26 F R C Yes No6 19 F R 1 No No7 24 F R 2 Yes No8 32 M R 2 Yes No9 11 M R 1 No No

10 18 F L 1 No No11 24 M R 1 No Yes12 17 F L 1 No No13 17 M R 59%:41% 1 No No14 29 M R 60%:40% 2 Yes No15 22 M R 68%:32% 2 No Yes16 25 M L 46%:54% 1 No No17 16 F R 56%:44% 1 No Yes18 22 F R 62%:38% 1 No No19 20 F L 43%:57% C Yes Yes20 18 F L 44%:56% 1 No No21 28 F R 62%:38% 1 No No22 19 F L 46%:54% 1 Yes No23 14 F R 65%:35% 1 Yes No24 35 M L 39%:61% 1 No No25 24 F R 57%:43% 2 No No26 14 F R 58%:42% 1 No No27 42 F L 38%:62% 1 No No28 21 F L 43%:57% 1 Yes No29 26 F L 36%:64% 1 Yes Yes30 36 F R 60%:40% C Yes No31 22 F R 57%:43% C Yes No32 16 M R 57%:43% 1 No No33 24 M L 44%:56% 1 No No34 13 F L 43%:57% 1 Yes No35 17 F R 58%:42% 1 No No36 25 F R 60%:40% 1 No No

Abbreviations: C, combination of 2 clinical types; SPECT, single photon emission computed tomography; TMJ, temporoman-dibular joint.

*Clinical type according to classification of Obwegeser and Makek.6



www.fedicom.org

o

atients (11.1%).(11.1%).ain or clicking ofclicking of

36.1%).).formed on all 36 sub-all 36 sub-

appreciable asymmetryciable asymmetryhe maximum differenceaximum diffe

s 68% to 32%. The meanto 32%. Thed condyle was 59.04% (SDe was 59.04%

fected condyle showed a lowe showedD, 3.56) (Table 22( ).).

of the histologic sections,e histologic sectpersistent layer of undiffestent layer of un

ells and a layer of hypertrond a layer of hyence of cartilage rests in thof cartilage rests

ification into types accordinon into types acer was only performed inonly perform

LAR HYPERPLA

www.fedico

Clinical Type* TMJ Symppe* TMJ

1 N1222222

CC 1 2 2 2 2 1 1 1

L R 59%:41%59%:41%R 60%:40%60%:40R 68%:32%68%:32%L 46%:54%L 46%:54%R 56%:44%R 56%:44R 62%:38%R 62%

F L 43%:57%LF L 44%:56LF R 62%:3RF L 46%F LF R 6F RM LM LF RF

4 F RF42 F LF21 F LF26 F6 F36 F36 F22 F22 F16 M16

3 24 M2434 13 F1335 171736 2525

Abbreviations: C, combinbbreviations: C, cdibular joint.ibular j

*Clinical type accorClinical

Villanueva-Alcojol, MVillanueva-A

CONDYLEYLE

depicted in Figure 1. None of the samples was classi-fied as type IV. We only found types I, II, and III in ourseries. Type I was the most frequently observed(44.4%), followed by type III (38.9%). Only 16.7% ofthe patients showed type II CH (Fig 2).

A possible association between patient age andhistologic type, as suggested by Slootweg and Mller,was evaluated, without a statistically significant asso-ciation.

When analyzing our results, we observed that allthe patients with type II CH presented with symp-toms, such as pain and clicking. In type III patients,some had symptoms and some did not. Conversely,none of the patients with type I CH had any problemsin relation to the TMJ. Our statistical analysis showedan association between histologic type and the pres-ence of joint symptoms (P .0049).

On the other hand, we could not find a relationshipbetween histologic type and uptake of the affectedcondyle on bone SPECT.

The mean follow-up was 4.3 years. Occlusion andfacial symmetry improved in all patients postopera-tively, and no recurrence was noted in any patient(Figs 3, 4). Six patients required orthognathic surgeryor esthetic surgery to correct residual deformity dur-ing the follow-up period (4 bimaxillary surgeries, 2mentoplasties, and an angle prosthesis). Furthermore,we observed, in accordance with other authors, thatthe function of the joint was unimpaired and painfree.22 The clinical examination showed a normalmaximum interincisal opening and lateral excursionsbefore and after surgery. High condylectomy left anormally functioning joint. No long-term joint mor-bidity in patients treated in this way has yet beenobserved.

Discussion

Rowe2 defined mandibular CH as an entity thatproduces an asymmetry of the mandible resultingfrom an enlargement of one side that is not due toneoplasia or dysplasia.

Traditionally, it has been reported that CH afflictsmale patients and female patients in equal propor-tions.23,24 Moreover, some authors have even indi-cated that this condition is more common in malepatients.25 However, a female predisposition has beennoted in other studies,20 and, indeed, our group in-cluded more female patients than male patients (ratio,25:11), in agreement with other reports of ratios of7:27 and 3:1.5,21 In light of our results, we can statethat treatment was more commonly sought by femalepatients than by male patients.

With regard to preferential laterality, an equal sidedistribution has been found by some authors, whereasothers have found that the left side is more frequentlyaffected.26 In our study, the right side was moreaffected, with a ratio of 11:7 (22 right and 14 left).This result is consistent with other reports.21,27

Nitzan et al21 found that this preferential laterality washighly gender dependent, with the right side predom-inating in female patients and the left side predomi-nating in male patients. Nevertheless, we have notfound this association in our series.

With respect to clinical classification depending onthe growth vector, a prevalence ratio between types1 and 2 of approximately 15:1 has been reported.28 Inour group of patients, this ratio was 3:1, and more-over, we found 4 patients with a combination of bothvertical and horizontal asymmetry. Our results (type 1in 66.7% of patients, type 2 in 22.2%, and a combina-tion of transverse and vertical asymmetry in 11.1%)are similar to those of Nitzan et al,21 who reportedfrequencies of 53%, 31%, and 16% for type 1, type 2,and a combination of the 2 entities, respectively.

The scintigraphic results showed hyperactivity ofone of the condyles consistent with clinical findings.It is important to emphasize that SPECT results shouldbe interpreted in light of a full clinical, radiographic,and cephalometric evaluation. It should be borne inmind that this method of bone scanning, thoughhighly sensitive, is nonspecific and does not necessar-ily correlate with active growth because it can also bethe result of inflammatory conditions, infection, heal-ing after traumatic injuries, and neoplastic lesions.Bone SPECT scintigraphy should not be used as thesole determinant of the need for condylar resection.

In describing the histologic characteristics of spec-imens of hyperplastic condyles that were surgically re-moved, similar to other authors,5,12 we have observed thepresence of an interrupted layer of undifferentiated mes-enchymal cells and a hypertrophic cartilage layer. Another

0%5%

10%15%20%25%30%35%40%45%50%

CH I CH II CH III

Histologic types

FIGURE 1. Distribution of histologic types.

Villanueva-Alcojol, Monje, and Gonzlez-Garca. Hyperplasia ofthe Mandibular Condyle. J Oral Maxillofac Surg 2010.


www.fedicom.org

off

andandMller,Mller,

cant asso-t asso-

erved that allhat aed with symp-symp-

type III patients,III patients,id not. Conversely,t. Conversely

CH had any problemsCH had any problemtistical analysis showedtistical analysis showe

ologic type and the pres-ogic type and the pP .0049).0049).

e could not find a relationshnot find a relape and uptake of the affee of the

ECT.w-up was 4.3 years. Occluswas 4.3 years. O

improved in all patients poved in allrecurrence was noted inrrence was no

ix patients required orthogtients required oc surgery to correct residuaery to correct

follow-up period (4 bimaxw-up period (4oplasties, and an angle prosts, and

observed, in accordance wved, in accoe function of the joint waction of the jo

free.22 The clinical examihe clinical emaximum interincisal opximum interincbefore and after surgeefore and afternormally functioningnormallbidity in patients tbidity inobserved.observed.

as an entity thatentitymandible resultingle resulting

de that is not due tot is not due to

reported that CH afflictsed that CH apatients in equal propor-s in equal pr

me authors have even inds have eveion is more common in mo

a female predisposition hasmale predispositudies,200 and, indeed, our gand, indeed,

male patients than male patietients than maleement with other reportsnt with other re

5,21 In light of our results,n light of ourment was more commonly swas more commothan by male patients.male patien

h regard to preferential lateard to preferentiibution has been found by son has been foun

hers have found that the lefve found thataffected.266 In our study, tIn our stuaffected, with a ratio ofcted, with a ratiThis result is consistehis result isNitzan et alNitzan et al2121 found thfhighly gender depenhighly genderinating in femaleinating in fenating in malenatinfound this assfound t

With respWitthe growtthe1 and 21 aour goverve

555

structural feature observed consistently in hyperplasticcondyles is the distribution of cartilage rests in the sub-chondral spongiosa, which is histologic proof of progres-sive lengthening of the condyle.

Given the retrospective character of the study, al-though all the cases were confirmed histopathologi-cally to have mandibular CH, only 18 were dividedaccording to the classification of Slootweg and Mller.

In all the patients with increased radionuclide up-take, we observed the histologic characteristics ofCH. However, when analyzing a possible associationbetween the activity level of the affected condyle onscintigraphic examination and the histologic featuresof a determined type of CH according to the Slootwegand Mller classification, we could not find consistentresults in our series.

Gray et al5 reported that the increase in uptake wasdirectly related to the frequency and penetrationdepth of the cartilage islands. They also reported thatthose patients who had marked uptake on the scinti-scan also had a higher frequency of cartilage islands,and the depth at which they were found was greater.However, they did not correlate these findings withhistologic types.

Slootweg and Mller12 found that the results ofscintigraphy did not correlate with histologic growthevidence. On the other hand, they assumed that therewas a correlation between histologic growth activityand age, with type I being more frequently found inpatients younger than 20 years of age and type IIbeing more common in patients over 20 years of age.They indicated that type III would be more frequently

FIGURE 2. Histopathologic examination. A, Type I CH. The photomicrograph shows a broad proliferation area. Cartilage islands arepresent within the bony trabeculae (hematoxylin-eosin stain, original magnification 20). B, Cartilage island in deep layers of trabecularbone (4.6 mm deep from surface) of a hyperplastic condyle. C, Type II CH. Cartilage rests are less frequent in the spongy bone than in typeI (hematoxylin-eosin stain, original magnification 10). D, Type III CH, showing more distorted layered pattern (hematoxylin-eosin stain,original magnification 10).



www.fedicom.org

bserved consistently in hyped consistently instribution of cartilage rests inn of cartilage re

osa, which is histologic proofhich is histolong of the condyle.e condyle.

e retrospective character oospective characl the cases were confirmedcases were co

have mandibular CH, onlymandibular CHding to the classification of Sthe cla

n all the patients with increhe patients wke, we observed the histoe observed th

CH. However, when analyHowever, whenbetween the activity leveween the activscintigraphic examinatcintigraphic examof a determined typef a deteand Mller classificand Mlleresults in our serresults in o

. A, Type I CH. The photomicroype I CH. The pmatoxylin-eosin stain, original magmatoxylin-eosin stain, orighyperplastic condyle.hyperplastic condyle. CC, Type II C, T

magnificationagnification 10).10). DD, Type III C, Typ

Gonzlez-Garca. Hyperplasia olez-Garca. Hyp

CONDYLEYLE

found in older patients. In our group, when we triedto find an association between age and the varioushistologic appearances of the condyle, a statisticallysignificant relationship was not encountered.

Nevertheless, we found a significant correlationbetween histologic type and the presence or absenceof symptoms (P .0049). Particularly, we observedthat all patients with type II CH had clinical manifes-tations such as pain and joint sounds. Among the typeIII patients, some were symptomatic and the rest didnot report any disturbance in relation to the TMJ.Conversely, none of the patients with type I CH hadany joint symptoms. To our knowledge, this associa-tion has not been reported in the literature until now,and it could suggest that histologic types representdifferent stages of the pathologic entity, with theonset of symptoms as the illness becomes more evi-dent and their disappearance as the fibrosis develops.Type I CH could be considered as a first phase ofproliferation in which there are no symptoms yet.These would start in a latter phase (type II CH) ofpatchy activity, and patients would probably becomeasymptomatic again as the fibrosis generalizes andhyaline cartilage disappears (type III CH). However,because this study was conducted in a relatively smallgroup of patients, the results cannot be generalized tothe whole population of CH patients. They first needto be confirmed in further studies in larger series.

Traditionally, the surgical methods used have con-sisted primarily of orthognathic surgery for correction ofthe asymmetry when further growth is not anticipated.Motamedi27 performs unilateral or bilateral ramus os-teotomy when growth is complete. Macintosh29 leavesthe articulation surgically undisturbed, allows the hyper-plasia to run its course, and then treats its sequelae withappropriate osteotomies. In our opinion, this optionoften means waiting a long time, and consequently, thepatient may have functional and esthetic disturbances,associated with psychosocial problems derived from asevere facial deformity. Moreover, the magnitude of thedeformity and its compensatory changes in the maxillaand dentoalveolar structures could compromise clinicaltreatment outcomes. Some authors perform a bimaxil-lary operation including resection of the involved con-dyle in the same procedure. Wolford et al28 and Shefferet al30 propose orthognathic surgery and simultaneoushigh condylectomy to correct the asymmetry.

In our opinion, basic considerations in the manage-ment of facial asymmetry caused by active CH mustinclude control of the growth process to allow morebalanced facial development. If evidence of abnormalcondylar growth is present, then condylar surgeryshould be undertaken before a severe facial deformitydevelops.31 It is expected that the removal of thecondyle will arrest the excessive and disproportionategrowth of the mandible in the diseased region and

FIGURE 3. A, B, and C, Unilateral mandibular type II CH in a 24-year-old patient. The elongation of the left side of the face, chin deviation, andcanting of the occlusal plane should be noted. The mandibular midline isnot deviated. D, E, and F, Patient at 2 years after high condylectomy,showing significantly improved facial harmony and good occlusal result.

Villanueva-Alcojol, Monje, and Gonzlez-Garca. Hyperplasia of theMandibular Condyle. J Oral Maxillofac Surg 2010.


www.fedicom.orgwhen we triedwe triedand the varioushe variousdyle, a statisticallya statisticncountered.ed.significant correlationcant correlationthe presence or absenceesence or ab

Particularly, we observedlarly, we obse II CH had clinical manifesad clinical m

joint sounds. Among the tyAmongre symptomatic and the resc and

turbance in relation to thnce in relationof the patients with type Ie patients with

oms. To our knowledge, thTo our knowledeen reported in the literatueported in the lit

d suggest that histologic tygest that histolostages of the pathologicof the pathol

f symptoms as the illness bs as the iland their disappearance as their disappearanc

e I CH could be considerH could beroliferation in which thereion in which

These would start in a latould start inpatchy activity, and patiechy activity, andasymptomatic again assymptomatichyaline cartilage disahyaline cartilabecause this study wecause this sgroup of patientsgroup of pathe whole poputhe wto be confirmto be c

TraditionTrasisted primsistthe asymthMotamteotth

IGURE 3. AA,, BB, and, and CC, Unilateral m, UniCCold patient. The elongation of the leftient. The elongation ocanting of the occlusal plane shoung of the occlusal pnot deviated.deviated. DD,,DD EE, and, andEE F, PatiFshowing significantly improvehowing significantly i

Villanueva-Alcojol, MonjeVillanueva-AMandibular Condyle. JMandibular C

777

can therefore limit progressive asymmetry during theactive phase and provide stable long-term results.Orthodontic treatment after surgery can correct oc-clusal and esthetic deformity definitively without ad-

ditional surgical interventions in most cases. If not,secondary correction by mandibular or maxillary os-teotomies or both can be appropriate to correct anyresidual occlusal and facial asymmetry. In generalterms, if a high condylectomy has been performedand posterior orthognathic surgery is necessary, thissecond operation will be easier.

High condylectomy (removal of 4 to 5 mm of thecondyle) instead of condylar shaving (removal of 2 to3 mm of the condyle) is our preferred method. Thepresence of cartilage islands in the cancellous boneshows that the pathology is not limited to the carti-lage surface. Masses of hyaline cartilage extendinginto the cancellous bone of the condylar neck havebeen identified in our samples. Therefore, not onlythe cartilage surface but also the subchondral boneshould be removed to eliminate the growth center.

In summary, we could not find any significant as-sociation between age and histologic type or betweenbone SPECT and histologic type. However, a signifi-cant association between histologic type and TMJsymptoms was observed. High condylectomy com-bined with orthodontics achieved optimal estheticand functional results and constituted the unique anddefinitive treatment in 30 of 36 patients.

Acknowledgments

The authors thank Dr Fernandez de Mera for the histologicanalysis.

References1. Adams R: Case history of Mary Keefe, in Medical Section of the

British Association, Bristol Meeting, 18362. Rowe NL: Aetiology, clinical features and treatment of mandib-

ular deformity. Br Dent J 108:41, 19603. Norman JE, Painter DM: Hyperplasia of the mandibular condyle. A

historical review of important early cases with a presentation andanalysis of twelve patients. J Maxillofac Surg 8:161, 1980

4. Papavasiliou A, Sawyer R, Lund V, et al: Benign conditions ofthe temporomandibular joint: A diagnostic dilemma. Br J OralSurg 21:222, 1983

5. Gray RJ, Sloan P, Quayle AA, et al: Histopathological and scin-tigraphic features of condylar hyperplasia. Int J Oral MaxillofacSurg 19:65, 1990

6. Obwegeser H, Makek M: Hemimandibular hyperplasiaHemi-mandibular elongation. J Maxillofac Surg 14:183, 1986

7. Egyedi P: Aetiology of condylar hyperplasia. Aust Dent J 14:12, 19698. Yang J, Lignelli JL, Ruprecht A: Mirror image condylar hyper-

plasia in two siblings. Oral Surg Oral Med Oral Pathol OralRadiol Endod 97:281, 2004

9. Oberg T: Unilateral hyperplasia of the mandibular condylar process:A histological, microradiographic and autoradiographic examinationof one case. Acta Odontol Scand 20:485, 1962

10. Hansson T, Solberg WK, Penn MK, et al: Anatomic study of the TMJsof young adults. A pilot investigation. J Prosthet Dent 41:556, 1979

11. Scapino RP: Histopathology associated with malposition of the hu-man temporomandibular joint disc. J Prosthet Dent 55:382, 1983

12. Slootweg PJ, Mller H: Condylar hyperplasia. A clinico-patho-logical analysis of 22 cases. J Maxillofac Surg 14:209, 1986

13. Saridin CP, Raijmakers P, Becking AG: Quantitative analysis of planarbone scintigraphy in patients with unilateral condylar hyperplasia.Oral Surg Oral Med Oral Pathol Oral Radiol Endod 104:259, 2007

FIGURE 4. Unilateral mandibular type I CH in a 14-year-oldpatient. A, B, and C, Preoperative frontal, lateral, and intraoralpictures. The deviation of the chin and the interincisal mandibularline toward the left side should be noted. D, E, and F, Patient at 2.5years after high condylectomy. The deviation of the chin andinterincisal mandibular line has been corrected.

Villanueva-Alcojol, Monje, and Gonzlez-Garca. Hyperplasia ofthe Mandibular Condyle. J Oral Maxillofac Surg 2010.


wwcan therefore limit proan therefore limactive phase and prctive p

Orthodontic treatmOrthodonclusal and esthetclusal and

ww.fedicom.orgcases. If not,s. If not,or maxillary os-axillary os-ate to correct anycorrect ammetry. In generaln generalhas been performedbeen performedurgery is necessary, thisy is necessary

asier.emoval of 4 to 5 mm of the4 to 5 mm

dylar shaving (removal of 2(remova) is our preferred method.rred

ge islands in the cancellouands in the cancathology is not limited to tgy is not limite

Masses of hyaline cartilageof hyaline carellous bone of the condylabone of the co

fied in our samples. Theren our samples.age surface but also the surface but also t

be removed to eliminate thoved to eliminsummary, we could not finmary, we could n

ation between age and histobetween ageone SPECT and histologic tCT and histo

cant association betweenciation betwsymptoms was observedmptoms was obbined with orthodontined with orand functional resultsnd functionaldefinitive treatmenefinitive trea

AcknowledgmeAckn

The authorsThe aanalysis.analysi

Refe1.

nilateral mandibular type I CHandibular typeand CC, Preoperative frontal, lat, Preoperative

e deviation of the chin and the intion of the chin and the left side should be noted.ft side should be no D

fter high condylectomy. The devh condylectomy. Tcisal mandibular line has been cobular li

anueva-Alcojol, Monje, and Gona-Alcojol, Monje, ahe Mandibular Condyle. J Oral Mbular Condyle. J

CONDYLEYLE

14. Hodder SC, Rees JIS, Oliver TB, et al: SPECT bone scintigraphyin the diagnosis and management of mandibular condylar hy-perplasia. Br J Oral Maxillofac Surg 38:87, 2000

15. Bohuslavizki KH, Brenner W, Kerscher A, et al: The value of bonescanning in the pre-operative decision-making in patients with pro-gressive facial asymmetry. Nucl Med Commun 17:562, 1996

16. Cisneros GJ, Kaban LB: Computerized skeletal scintigraphy for theassessment of mandibular asymmetry. J Oral Maxillofac Surg 42:513,1984

17. Pogrel MA: Quantitative assessment of isotope activity in the tem-poromandibular joint region as a means of assessing unilateral con-dylar hypertrophy. Oral Surg Oral Med Oral Pathol 60:15, 1985

18. Hansson T, Oberg T, Carlsson GE, et al: Thickness of the softtissue layers and the articular disk in the temporomandibularjoint. Acta Odontol Scand 35:77, 1977

19. Eslami B, Behnia H, Javadi H, et al: Histopathologic comparisonof normal and hyperplastic condyles. Oral Surg Oral Med OralPathol Oral Radiol Endod 96:711, 2003

20. Angiero F, Farronato G, Benedicenti S, et al: Mandibular con-dylar hyperplasia. Clinical, histopathological and treatmentconsiderations. Cranio 27:24, 2009

21. Nitzan D, Katsnelson A, Bermanis I, et al: The clinical charac-teristics of condylar hyperplasia: Experience with 61 patients.J Oral Maxillofac Surg 66:312, 2008

22. Lippold C, Kruse-Losler B, Danesh G, et al: Treatment of hemi-mandibular hyperplasia: The biological basis of condylectomy.Br J Oral Maxillofac Surg 45:353, 2007

23. Henderson MJ, Wastie ML, Bromige L, et al: Technetium-99mbone scintigraphy and mandibular condylar hyperplasia. ClinRadiol 41:411, 1990

24. Matteson SR, Proffit WR, Terry BC, et al: Bone scanning with99m technetium phosphate to assess condylar hyperplasia.Oral Surg Oral Med Oral Pathol 60:356, 1985

25. Worth HM: Radiology of the temporomandibular joint, in ZarbGA, Carlsson GE (eds): Temporomandibular Joint Function andDysfunction. Copenhagen, Munksgaard, 1979, p 334

26. Iannetti G, Cascone P, Belli E, et al: Condylar hyperplasia:Cephalometric study, treatment planning and surgical correc-tion (our experience). Oral Surg Oral Med Oral Pathol 68:673,1989

27. Motamedi MH: Treatment of condylar hyperplasia of the man-dible using unilateral ramus osteotomies. J Oral Maxillofac Surg54:1161, 1996

28. Wolford LM, Mehra P, Reiche-Fischel, et al: Efficacy of highcondylectomy for management of condylar hyperplasia. Am JOrthod Dentofac Orthop 121:136, 2002

29. Macintosh RB: Treatment of condylar hyperplasia of the man-dible using unilateral ramus osteotomies. J Oral Maxillofac Surg54:1169, 1996

30. Sheffer MA, Corso A, Tomazi M, et al: Condylar hyperplasiatreated by simultaneous orthognathic surgery and high condy-lectomy. A case report. Rev Odont Cienc 23:407, 2008

31. Chen YR, Bendor-Samuel R, Huang CS: Hemimandibular hyper-plasia. Plast Reconstr Surg 97:730, 1996


Technetium-99metium-99mar hyperplasia. Clinplasia. Clin

al: Bone scanning withscanning wss condylar hyperplasia.hyperplasia.

356, 198585oromandibular joint,ndibular joint, in ZarbZa

mandibular Joint Function andular Joint Functiunksgaard, 1979, p 334d, 1979, p 334

i E, et al: Condylar hyperplasiaCondylar hypement planning and surgical correng and surgica

ral Surg Oral Med Oral Pathol 68:6Oral Pat

ment of condylar hyperplasia of tf condylar hyperplaal ramus osteotomies. J Oral Maxils osteotomies. J Ora

ehra P, Reiche-Fischel, et al: Effi, Reiche-Fischel, ety for management of condylar hyanagement of cond

tofac Orthop 121:136, 2002rthop 121:136,RB: Treatment of condylar hypereatment of condyla

ng unilateral ramus osteotomies. Jateral ramus osteoto9, 1996

fer MA, Corso A, Tomazi M, et aCorso A, Tomaziated by simultaneous orthognathiy simultaneous ortho

ectomy. A case report. Rev Odon. A case report.Chen YR, Bendor-Samuel R, HuanR, Bendor-Samueplasia. Plast Reconstr Surg 97:7Plast Reconstr Su

999

HiperplasiaCondilo2

Documents

Hyperplasia of the Mandibular Condyle: Clinical, Histopathologic…fedicom.org/wp-content/uploads/2011/08/HiperplasiaCondi... · 2017-03-24 · Hyperplasia of the Mandibular Condyle: